Healthcare Provider Details

I. General information

NPI: 1285912832
Provider Name (Legal Business Name): MELINDA JO WOLTERS LA SALLE MSN, ACNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MELINDA JO CRAIN

II. Dates (important events)

Enumeration Date: 08/01/2011
Last Update Date: 04/04/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

915 N GRAND BLVD
SAINT LOUIS MO
63106-1621
US

IV. Provider business mailing address

4100 FOREST PARK AVE APT 205
SAINT LOUIS MO
63108-2885
US

V. Phone/Fax

Practice location:
  • Phone: 314-652-4100
  • Fax:
Mailing address:
  • Phone: 314-709-8322
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number2010031271
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number2011015338
License Number StateMO
# 3
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number2011015338
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: